Waiting List Reservation Form - Bereaved Families

• Requested Dates of Stay
  (please reference our programming calendar and fill in the appropriate date(s) for your desired weekend that is currently full)
  

• Please share the name of your child who has died*

• Date of Birth*
• Cause of Death*
• Age at Time of Death*
• Date of Death*
• Gender*

• Parent 1 First Name*
• Parent 1 Last Name*
• Parent 2 First Name
• Parent 2 Last Name
• Home Address*
• City*
• State*
• Zip*
• Home Phone*
• Cell Phone (Parent 1)*
• Cell Phone (Parent 2)
• Work Phone (Parent 1)
• Work Phone (Parent 2)
• Email Address*
• Alternate Email Address

Family weekends at Faith's Lodge are for parents and surviving children (immediate family) only.

• Name
• Birthday
• Relationship

• Name
• Birthday
• Relationship

• Name
• Birthday
• Relationship

• Name
• Birthday
• Relationship

• Name
• Birthday
• Relationship

• Name*
• Address*
• Home Phone*
• Cell Phone*

• Person completing this application*

• Referral Source

  I was referred to Faith's Lodge by:*

  Abbott Northwestern/ Mother Baby CenterBeliEVE FoundationBest Christmas EverCoulee Region Angels of HopeEthan's ReasonGundersen (RTS)Ridgeview Medical CenterHalos of the St. Croix ValleyLasting ImprintOpsahl-Kostel Funeral HomeRehkamp-Horvath Funeral ServicesSomeone elseI was not referred by anyone
• Referrer Details

  First and Last Name
  Occupation/Relationship to the Bereaved

  Referrer Details

  First and Last Name
  Phone
  Occupation/Relationship to the Bereaved
  Referring Organization (hospital, church, etc)

• Hospital or Organization Treated At*
• City*
• State*
• Attending physician

• If a spot opens up, I am unable to afford my stay at Faith's Lodge and would like to request financial assistance

• In 500 words or less, explain your family’s need for scholarship assistance from Fund a Family and how your family would benefit from staying at Faith’s Lodge. Scholarships are reserved for first-time guests. All return-guest scholarship requests will be reviewed by the Faith's Lodge Team and will be awarded based on scholarship availability.

• How much can you pay in addition to the $50 Reservation Fee?

• Gift Certificate Code
  Please enter the code from the lower left corner of your gift certificate

• I am a past guest and have stayed at Faith's Lodge before. I understand I have to pay the return guest rate.

• My family has 6 or more members and I am interested in reserving more than one (1) room for my family at an additional cost.

• Faith’s Lodge Photo & Video Release Consent (optional): I/We hereby give to Faith’s Lodge, its successors or assigns, the unconditional right to use and reproduce in any of its printed and online publications (including but not limited to newsletters, annual reports, websites, social media posts and blog posts) all pictures, videos and duplicates thereof, that it have obtained of myself and/or my child(ren).

• I understand and recognize my waiting list status at Faith’s Lodge is contingent on availability and approval of this application as well as compliance with all conditions, qualifications and restrictions designated by Faith’s Lodge.